Clinical Destiny of Indeterminate Pulmonary Nodules in Patients Undergoing Radical Cystectomy for Urothelial Carcinoma of the Bladder
Sources of Funding: None
Introduction
Perioperative risks and significant quality of life concerns following radical cystectomy (RC) render accurate pre-operative staging paramount. Incidental indeterminate pulmonary nodules (IPNs) are a common pre-operative finding in clinical practice, thus representing a significant management challenge since metastatic patients are unlikely to benefit from extirpation. Thus, we sought to evaluate the natural history of IPNs in a large institutional cohort that underwent RC._x000D_
Methods
We reviewed our institutional database for patients who underwent RC from 2000-2014 for urothelial carcinoma (UCC) of the bladder & had ≥1 identifiable pulmonary lesion on preoperative staging imaging measuring <2cm in any axis. Patients who were M1 at surgery or had non urothelial histology were excluded. Cumulative incidence of any lung metastasis was estimated, adjusting for competing risk of death; overall survival (OS) was estimating using Kaplan Meier methods. We sought to determine the natural history of these pulmonary lesions and evaluated predictors of metastatic etiology._x000D_
Results
During the study period, 681 RC were performed at our institution. Of which, 73 patients with an identifiable preoperative IPN met inclusion criteria & underwent RC. In this subset, 23% were female, 22% were active smokers & 55% former smokers. The median age at surgery was 70 yrs (range 43-88). 51% received neoadjuvant chemotherapy & 62% of RC were performed using the traditional open approach (vs 38% robotically). Final pathologic staging included 16% pT0N0Mx, 19% pTa/Tis/T1N0Mx, 43% pT2-4N0Mx, & 22% pTanyN+Mx. Median IPN size was 0.7±0.3cm. At median follow up of 23.5 months, the IPNs in 92% (67/73) of patients were clinically benign, with metastatic urothelial cancer confirmed in only 5 patients, & a primary lung malignancy diagnosed in 1 patient. In the IPN cohort, lung metastasis at non-IPN sites were detected in 2 additional patients. Cumulative incidence of any lung metastasis at 12, 24 & 36 months was 5.9% (95%CI 1.9-13.3%), 7.6% (95%CI 2.8-15.7%), & 10.3% (95%CI 3.9-20.2%), respectively. OS at 12, 24 & 36 months was 75.3% (95%CI 62.3-83.9%), 65.8% (95%CI 53-1-75.9%), & 54.0% (95%CI 39.7-66.2%), respectively. _x000D_
Conclusions
The majority of IPNs in patients who proceeded to RC for UCC of the bladder were stable upon follow-up & rarely represented malignancy. Patients with IPNs have OS consistent with previously published literature. As such, in appropriately screened UCC patients, IPNs should not be a barrier to proceeding with extirpative surgical therapy.
Funding
None
Brian McGreen
Albert Lee
Karen Ruth
Elizabeth Plimack
Daniel Geynisman
Matthew Zibelman
Benjamin Ristau
Marc Smaldone
Richard Greenberg
Rosalia Viterbo
David Chen
Robert Uzzo
Alexander Kutikov